The local food environment and diet: a systematic review

Identifying rural food deserts: Methodological considerations for food environment interventions

OBJECTIVES

Food insecurity in an important public health issue and affects 13% of Canadian households. It is associated with poor accessibility to fresh, diverse and affordable food products. However, measurement of the food environment is challenging in rural settings since the proximity of food supply sources is unevenly distributed. The objective of this study was to develop a methodology to identify food deserts in rural environments.

METHODS

In-store evaluations of 25 food products were performed for all food stores located in four contiguous rural counties in Quebec. The quality of food products was estimated using four indices: freshness, affordability, diversity and the relative availability. Road network distance between all residences to the closest food store with a favourable score on the four dimensions was mapped to identify residential clusters located in deprived communities without reasonable access to a "good" food source. The result was compared with the food desert parameters proposed by the US Department of Agriculture (USDA), as well as with the perceptions of a group of regional stakeholders.

RESULTS

When food quality was considered, food deserts appeared more prevalent than when only the USDA definition was used. Objective measurements of the food environment matched stakeholders' perceptions.

CONCLUSION

Food stores' characteristics are different in rural areas and require an in-store estimation to identify potential rural food deserts. The objective measurements of the food environment combined with the field knowledge of stakeholders may help to shape stronger arguments to gain the support of decision-makers to develop relevant interventions.

The food environment and diet quality of urban-dwelling older women and men: Assessing the moderating role of diet knowledge

OBJECTIVES

The relationships between local food environments and dietary patterns are important for older adults and could be different in men and women. We examined associations between exposure to neighbourhood food sources and food consumption and the moderating role of diet knowledge separately among older women and men living in Montreal in 2003-2005 (n = 722).

METHODS

The proportion of fast-food outlets relative to all restaurants (%FFO) and the proportion of healthy food stores relative to all stores (%HFS) were estimated for 500 m buffers around participants' homes. Two dietary patterns, designated "Western" and "prudent", reflecting lower- and higher-quality diets respectively, were identified from food frequency questionnaire data. The unique and interactive effects of diet knowledge and food-source exposure on diet scores were tested with separate linear regression models for women and men.

RESULTS

For men, greater %FFO exposure was related to lower prudent diet scores (β = -0.18, p = 0.02), but no effect of %HFS exposure was observed and no interactions were statistically significant. For women, an inverse relationship between %FFO and prudent diet scores was strongest among those with low diet knowledge (β = -0.22, p < 0.01). No other associations were statistically significant.

CONCLUSION

Older men's diet patterns may reflect unhealthy cues associated with fast-food outlets. Among women, diet knowledge potentiated both negative and positive relationships with the food environment. In the absence of consistent main effects of the food environment on diet scores, subgroup analysis is a promising avenue for research.

Retail food environments research in Canada: A scoping review

OBJECTIVES

The field of retail food environments research is relatively new in Canada. The objective of this scoping review is to provide an overview of retail food environments research conducted before July 2015 in Canada. Specifically, this review describes research foci and key findings, identifies knowledge gaps and suggests future directions for research.

METHODS

A search of published literature concerning Canadian investigations of retail food environment settings (food stores, restaurants) was conducted in July 2015 using PubMed, Web of Science, Scopus, PsychInfo and ERIC. Studies published in English that reported qualitative or quantitative data on any aspect of the retail food environment were included, as were conceptual papers and commentaries.

SYNTHESIS

Eighty-eight studies were included in this review and suggest that the field of retail food environments research is rapidly expanding in Canada. While only 1 paper was published before 2005, 66 papers were published between 2010 and 2015. Canadian food environments research typically assessed either the socio-economic patterning of food environments (n = 28) or associations between retail food environments and diet, anthropometric or health outcomes (n = 33). Other papers profiled methodological research, qualitative studies, intervention research and critical commentaries (n = 27). Key gaps in the current literature include measurement inconsistency among studies and a lack of longitudinal and intervention studies.

CONCLUSION

Retail food environments are a growing topic of research, policy and program development in Canada. Consistent methods (where appropriate), longitudinal and intervention research, and close partnerships between researchers and key stakeholders would greatly advance the field of retail food environments research in Canada.

Retail food environments in Canada: Maximizing the impact of research, policy and practice

Retail food environments are gaining national and international attention as important determinants of population dietary intake. Communities across Canada are beginning to discuss and implement programs and policies to create supportive retail food environments. Three considerations should drive the selection of food environment assessment methods: relevance (What is the problem, and how is it related to dietary outcomes?); resources (What human, time and financial resources are required to undertake an assessment?); and response (How will policy-makers find meaning out of and act on the information gained through the food environment assessment?). Ultimately, food environment assessments should be conducted in the context of stakeholder buy-in and multi-sectoral partnerships, since food environment solutions require multi-sectoral action. Partnerships between public health actors and the food and beverage industry can be challenging, especially when mandates are not aligned. Clarifying the motivations, expectations and roles of all stakeholders takes time but is important if the impact of food environment research, policy and practice is to be maximized. The articles contained in this special supplementary issue describe ongoing food environments research across Canada and fill some of the important gaps in the current body of Canadian food environments literature.

An examination of the roles played by early adolescent children in interactions with their local food environment

OBJECTIVES

The purpose of this study was to examine how pre- and early adolescent (10-14 years old) children from a wide range of neighbourhoods interact with their local food environment (FE), with a focus on the foods and food sources they access and their locations. Children in this age group are developing independence and mobility within (and beyond) their home neighbourhoods but are somewhat geographically bound as they cannot yet drive.

METHODS

This research consists of qualitative interviews with 31 children (15 males, 16 females) aged 10-14 years living in socio-economically diverse neighbourhoods across Saskatoon, SK. A thematic analysis was conducted.

RESULTS

Children's descriptions of what constitutes their neighbourhood FE were varied, ranging from a couple of city blocks to several kilometres from home. Children were familiar with the types of establishment that sell food within their perceived neighbourhood. When children purchased their own food they most frequently cited buying snacks such as ice cream, candy and slushes, and the majority of these purchases were made in convenience stores, gas stations and grocery stores. Few children reported frequenting fast-food or other restaurants without adults, and when they did it was usually to buy snacks such as French fries and ice cream rather than meals.

CONCLUSIONS

Our results highlight the importance of interventions targeted to this age group, in which personal food choices were reported almost exclusively as being energy- but not nutrient-dense snack foods.

Retail food environments research: Promising future with more work to be done

As members of the scientific committee for the Food Environments in Canada conference, we reflect on the current state of food environments research in Canada. We are very encouraged that the field is growing and there have been many collaborative efforts to link researchers in Canada, including the 2015 Food Environments in Canada Symposium and Workshop. We believe there are 5 key challenges the field will need to collectively address: theory and causality; replication and extension; consideration of rural, northern and vulnerable populations; policy analysis; and intervention research. In addressing the challenges, we look forward to working together to conduct more sophisticated, complex and community-driven food environments research in the future.

Policy options for healthier retail food environments in city-regions

Public policy is central to health promotion: it determines the distribution of resources in a society and establishes the structural context for the actions of both corporations and consumers. With this in mind, the purpose of this paper is to begin a discussion on promising policy options for a health-promoting retail food environment. Drawing on specific municipal examples, we examine four groups of policy options for healthier retail food environments in city-regions: planning for health; transforming consumer environments; economic and fiscal instruments; and a culture of transparency and participation. We introduce examples of policy options that are receiving increasing attention in the public health and urban planning literature and that function at the municipal level. We also highlight how public health professionals have an important role to play in policy that shapes retail food environments, especially in making explicit the linkages between health and other policy goals. In doing so, this commentary aims to motivate public health practitioners in a variety of community contexts to consider the policy supports they need to advance their exploration, development, testing and evaluation of interventions for healthier retail food environments.

Neighborhood and home food environment and children's diet and obesity: Evidence from military personnel's installation assignment

Research and policy initiatives are increasingly focused on the role of neighborhood food environment in children's diet and obesity. However, existing evidence relies on observational data that is limited by neighborhood selection bias. The Military Teenagers' Environments, Exercise, and Nutrition Study (M-TEENS) leverages the quasi-random variation in neighborhood environment generated by military personnel's assignment to installations to examine whether neighborhood food environments are associated with children's dietary behaviors and BMI. Our results suggest that neither the actual nor the perceived availability of particular food outlets in the neighborhood is associated with children's diet or BMI. The availability of supermarkets and convenience stores in the neighborhood was not associated with where families shop for food or children's dietary behaviors. Further, the type of store that families shop at was not associated with the healthiness of food available at home. Similarly, availability of fast food and restaurants was unrelated to children's dietary behaviors or how often children eat fast food or restaurant meals. However, the healthiness of food available at home was associated with healthy dietary behaviors while eating at fast food outlets and restaurants were associated with unhealthy dietary behaviors in children. Further, parental supervision, including limits on snack foods and meals eaten as a family, was associated with dietary behaviors. These findings suggest that focusing only on the neighborhood food environment may ignore important factors that influence children's outcomes. Future research should also consider how families make decisions about what foods to purchase, where to shop for foods and eating out, how closely to monitor their children's food intake, and, ultimately how these decisions collectively impact children's outcomes.

Does neighborhood fast-food outlet exposure amplify inequalities in diet and obesity? A cross-sectional study

BACKGROUND

Greater exposures to fast-food outlets and lower levels of education are independently associated with less healthy diets and obesity. Little is known about the interplay between these environmental and individual factors.

OBJECTIVE

The purpose of this study was to test whether observed differences in fast-food consumption and obesity by fast-food outlet exposure are moderated by educational attainment.

DESIGN

In a population-based cohort of 5958 adults aged 29-62 y in Cambridgeshire, United Kingdom, we used educational attainment-stratified regression models to estimate the food-frequency questionnaire-derived consumption of energy-dense "fast foods" (g/d) typically sold in fast-food restaurants and measured body mass index (BMI; in kg/m(2)) across geographic information system-derived home and work fast-food exposure quartiles. We used logistic regression to estimate the odds of obesity (BMI ≥30) and calculated relative excess risk due to interaction (RERI) on an additive scale. Participant data were collected during 2005-2013 and analyzed in 2015.

RESULTS

Greater fast-food consumption, BMI, and odds of obesity were associated with greater fast-food outlet exposure and a lower educational level. Fast-food consumption and BMI were significantly different across education groups at all levels of fast-food outlet exposure (P < 0.05). High fast-food outlet exposure amplified differences in fast-food consumption across levels of education. The relation between fast-food outlet exposure and obesity was only significant among those who were least educated (OR: 2.05; 95% CI: 1.08, 3.87; RERI = 0.88), which suggested a positive additive interaction between education and fast-food outlet exposure.

CONCLUSION

These findings suggest that efforts to improve diets and health through neighborhood-level fast-food outlet regulation might be effective across socioeconomic groups and may serve to reduce observed socioeconomic inequalities in diet and obesity.

Retail Environments as a Venue for Obesity Prevention

Increasing attention has been given to the role of retail food environments in shaping dietary behavior and obesity risk. Studies have generally shown an association between living in a neighborhood with or in close proximity to certain types of food outlets and/or the availability of healthy food options and better dietary quality, higher fruit/vegetable intakes, and a lower risk of overweight, even after controlling for individual/family level characteristics. However, research in this area has yielded mixed results, overall. Future research needs to identify consistent approaches for defining and measuring food retail environments.

Eating patterns in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil): an exploratory analysis

The food consumption of 15,071 public employees was analyzed in six Brazilian cities participating in the baseline for Brazilian Longitudinal Study of Adult Health (ELSA-Brasil, 2008-2010) with the aim of identifying eating patterns and their relationship to socio-demographic variables. Multiple correspondence and cluster analysis were applied. Four patterns were identified, with their respective frequencies: "traditional" (48%); "fruits and vegetables" (25%); "pastry shop" (24%); and "diet/light" (5%) The "traditional" and "pastry shop" patterns were more frequent among men, younger individuals, and those with less schooling. "Fruits and vegetables" and "diet/light" were more frequent in women, older individuals, and those with more schooling. Our findings show the inclusion of new items in the "traditional" pattern and the appearance of the "low sugar/low fat" pattern among the eating habits of Brazilian workers, and signal socio-demographic and regional differences.

Perceived and geographic food access and food security status among households with children

OBJECTIVE

To examine the association of both perceived and geographic neighbourhood food access with food security status among households with children.

DESIGN

This was a cross-sectional study in which participants' perceptions of neighbourhood food access were assessed by a standard survey instrument, and geographic food access was evaluated by distance to the nearest supermarket. Multinomial logistic regression models were used to examine the associations.

SUBJECTS

The Midlands Family Study included 544 households with children in eight counties in South Carolina, USA. Food security status among participants was classified into three categories: food secure (FS), food insecure (FI) and very low food security among children (VLFS-C).

RESULTS

Compared with FS households, VLFS-C households had lower odds of reporting easy access to adequate food shopping. VLFS-C households also had lower odds of reporting neighbourhood access to affordable fruits and vegetables compared with FS households and reported worse selection of fruits and vegetables, quality of fruits and vegetables, and selection of low-fat products. FI households had lower odds of reporting fewer opportunities to purchase fast food. None of the geographic access measures was significantly associated with food security status.

CONCLUSIONS

Caregivers with children who experienced hunger perceived that they had less access to healthy affordable food in their community, even though grocery stores were present. Approaches to improve perceived access to healthy affordable food should be considered as part of the overall approach to improving food security and eliminating child hunger.

The Good Food Junction: a Community-Based Food Store Intervention to Address Nutritional Health Inequities

Background

This is a 2-year study to assess the early impacts of a new grocery store intervention in a former food desert.

Objective

The purpose of the study is to understand the early health effects of the introduction of a large-scale food and nutrition-focused community-based population health intervention, the Good Food Junction (GFJ) Cooperative Store, in a geographically bounded group of socially disadvantaged neighborhoods (the “core neighborhoods”) in a midsized Canadian city. The GFJ grocery store was tasked with improving the access of residents to healthy, affordable food. The 5 research questions are: (1) What is the awareness and perception of the GFJ store among residents of the core neighborhoods? (2) Are there differences in awareness and perception among those who do and do not shop at the GFJ? (3) Will healthy food purchasing at the GFJ by residents of the core neighborhoods change over time, and what purchases are these individuals making at this store? (4) What early impact(s) will the GFJ have on key health-related outcomes (such as household food security status, vegetable and fruit intake, key aspects of self-reported mental health, self-reported health)? and (5) Are the effects of the intervention seen for specific vulnerable population groups, such as Aboriginal people, seniors (65 years old or older) and new immigrants (settled in Saskatoon for less than 5 years)?

Methods

The research project examined initial impacts of the GFJ on the health of the residents in surrounding neighborhoods through a door-to-door cross-sectional survey of food access and household demographics; an examination of GFJ sales data by location of shoppers' residences; and a 1-year, 3-time-point longitudinal study of self-reported health of GFJ shoppers.

Results

Analyses are on-going, but preliminary results show that shoppers are using the store for its intended purpose, which is to improve access to healthy food in a former food desert.

Conclusions

To our knowledge this is the first large-scale study of a full-service grocery store intervention in a former food desert in Canada that has used multiple data sources, as well as longitudinal analyses, to examine its effects. Its findings will contribute significantly to the knowledge base on food environment interventions.

Models of Individual Dietary Behavior Based on Smartphone Data: The Influence of Routine, Physical Activity, Emotion, and Food Environment

INTRODUCTION

Smartphone applications (apps) facilitate the collection of data on multiple aspects of behavior that are useful for characterizing baseline patterns and for monitoring progress in interventions aimed at promoting healthier lifestyles. Individual-based models can be used to examine whether behavior, such as diet, corresponds to certain typological patterns. The objectives of this paper are to demonstrate individual-based modeling methods relevant to a person's eating behavior, and the value of such approach compared to typical regression models.

METHOD

Using a mobile app, 2 weeks of physical activity and ecological momentary assessment (EMA) data, and 6 days of diet data were collected from 12 university students recruited from a university in Kunming, a rapidly developing city in southwest China. Phone GPS data were collected for the entire 2-week period, from which exposure to various food environments along each subject's activity space was determined. Physical activity was measured using phone accelerometry. Mobile phone EMA was used to assess self-reported emotion/feelings. The portion size of meals and food groups was determined from voice-annotated videos of meals. Individual-based regression models were used to characterize subjects as following one of 4 diet typologies: those with a routine portion sizes determined by time of day, those with portion sizes that balance physical activity (energy balance), those with portion sizes influenced by emotion, and those with portion sizes associated with food environments.

RESULTS

Ample compliance with the phone-based behavioral assessment was observed for all participants. Across all individuals, 868 consumed food items were recorded, with fruits, grains and dairy foods dominating the portion sizes. On average, 218 hours of accelerometry and 35 EMA responses were recorded for each participant. For some subjects, the routine model was able to explain up to 47% of the variation in portion sizes, and the energy balance model was able to explain over 88% of the variation in portion sizes. Across all our subjects, the food environment was an important predictor of eating patterns. Generally, grouping all subjects into a pooled model performed worse than modeling each individual separately.

CONCLUSION

A typological modeling approach was useful in understanding individual dietary behaviors in our cohort. This approach may be applicable to the study of other human behaviors, particularly those that collect repeated measures on individuals, and those involving smartphone-based behavioral measurement.

An integrative literature review of small food store research across urban and rural communities in the U.S

OBJECTIVE

The purpose of this review was to identify how rural and urban food access differs across small food stores as well as the types of research strategies and methodologies that have been applied in each setting in the U.S.

METHODS

Manuscripts were included in the review if they were published in English over the past ten years, with a clear delineation between urban and/or rural, conducted in the U.S., and reported data from small food store research.

RESULTS

After elimination, 19 manuscripts representing rural (n = 5) and urban (n = 14) settings were included in the final review. The review was conducted in Nebraska between January 2015 and May 2015. Findings from the reviewed manuscripts revealed that rural communities might face different challenges with healthy food access in small food stores when compared to urban settings. In particular, small food stores in rural areas lacked healthy food options largely because storeowners perceived that their customers would not purchase healthier items and due to challenges with distribution. Conversely, studies reporting on small food stores in urban areas suggest challenges with transportation and safety concerns.

CONCLUSION

Research on small food stores is nascent and further research, especially intervention studies, is needed. Further, less evidence exists on healthy food access, in particular intervention testing on small food store research in rural areas.

Modified ground-truthing: an accurate and cost-effective food environment validation method for town and rural areas

Background

A major concern in food environment research is the lack of accuracy in commercial business listings of food stores, which are convenient and commonly used. Accuracy concerns may be particularly pronounced in rural areas. Ground-truthing or on-site verification has been deemed the necessary standard to validate business listings, but researchers perceive this process to be costly and time-consuming. This study calculated the accuracy and cost of ground-truthing three town/rural areas in Minnesota, USA (an area of 564 miles, or 908 km), and simulated a modified validation process to increase efficiency without comprising accuracy. For traditional ground-truthing, all streets in the study area were driven, while the route and geographic coordinates of food stores were recorded.

Results

The process required 1510 miles (2430 km) of driving and 114 staff hours. The ground-truthed list of stores was compared with commercial business listings, which had an average positive predictive value (PPV) of 0.57 and sensitivity of 0.62 across the three sites. Using observations from the field, a modified process was proposed in which only the streets located within central commercial clusters (the 1/8 mile or 200 m buffer around any cluster of 2 stores) would be validated. Modified ground-truthing would have yielded an estimated PPV of 1.00 and sensitivity of 0.95, and would have resulted in a reduction in approximately 88 % of the mileage costs.

Conclusions

We conclude that ground-truthing is necessary in town/rural settings. The modified ground-truthing process, with excellent accuracy at a fraction of the costs, suggests a new standard and warrants further evaluation.

The impact of a new McDonald's restaurant on eating behaviours and perceptions of local residents: A natural experiment using repeated cross-sectional data

Neighbourhood food environments are posited as an important determinant of eating behaviours; however causality is difficult to establish based on existing studies. Using a natural experiment study design (incorporating repeated cross-sectional data), we tested whether the development of a new McDonald's restaurant increased the frequency of consumption of McDonald's products amongst local residents in the suburbs of Tecoma (site of a new McDonald's restaurant development) and Monbulk (control site) in Victoria, Australia. Across both sites, the reported frequency of McDonald's consumption did not change during the follow-up surveys. In the context explored, the development of a new McDonald's restaurant has not resulted in an increased consumption of McDonald's products.

Increasing Community Access to Fresh Fruits and Vegetables: A Case Study of the Farm Fresh Market Pilot Program in Cobb County, Georgia, 2014

Background

Ecological models of health suggest that to effectively prevent chronic disease, community food environments must support healthy eating behaviors. However, disparities in access to healthy foods persist in the United States.

Community Context

The Farm Fresh Market (FFM) was a fruit and vegetable market that sold low-cost fresh produce in Cobb County, Georgia in 2014.

Methods

This case study describes the development of the FFM through a community engagement process and presents evaluation results from the project’s pilot implementation. Community engagement strategies included forming a community advisory board, conducting a needs assessment, and contracting with a community-based organization to implement the FFM.

Outcome

In the pilot year, the FFM served an average of 28.7 customers and generated an average of $140.20 in produce sales per market day. Most returning customers lived in the local community and reported a range of socioeconomic backgrounds. Most returning customers strongly agreed that the FFM made it easier (69.0%) and less expensive (79.0%) for them to buy fresh fruits and vegetables, reported that they ate more vegetables (65.0%) and fruit (55.0%) as a result of the FFM, and reported that they were very satisfied with the FFM overall (92.0%).

Interpretation

Results from this community case study underscore the importance of engaging communities in the development of community food environment interventions. Results also suggest that the FFM initiative was a feasible and acceptable way to respond to the community-identified public health priority of increasing access to healthy foods.

Associations between frequency of food shopping at different store types and diet and weight outcomes: findings from the NEWPATH study

Objective

The present study aimed to: (i) examine associations between food store patronage and diet and weight-related outcomes; and (ii) explore consumer motivations for visiting different types of food store.

Design

A stratified probability sample of residents completed household and individual-level surveys in 2009/2010 on food purchasing patterns and motivations, dietary intake, waist circumference (WC), weight and height. Diet quality was calculated using the Healthy Eating Index for Canada from a subset of participants (n 1362). Generalized estimating equations were created in 2015 to examine how frequency of patronizing different types of food store was associated with diet quality, intake of fruits and vegetable, mean intake of energy (kcal) sodium and saturated fat, WC and BMI.

Setting

Three mid-sized urban municipalities in Ontario, Canada.

Subjects

A representative sample of residents (n 4574).

Results

Participants who shopped frequently at food co-ops had significantly better diet quality (β=5·3; 99 % CI 0·3, 10·2) than those who did not. BMI and WC were significantly lower among those who frequently shopped at specialty shops (BMI, β=−2·1; 99 % CI −3·0, −1·1; WC, β=−4·8; 99 % CI −7·0, −2·5) and farmers’ markets (BMI, β=−1·4; 99 % CI −2·3, −0·5; WC, β=−3·8; 99 % CI −6·0, −1·6) compared with those who did not. Relative importance of reasons for food outlet selection differed by large (price, food quality) v. small (proximity, convenient hours) shopping trip and by outlet type.

Conclusions

Findings contribute to our understanding of food store selection and have implications for potentially relevant retail food intervention settings.

Place matters: Mitigating obesity with the person-in-environment approach

Research demonstrates that environmental and community-level variables contribute to obesity. Many of these variables are outside of personal volitional control, such as the characteristics of the places in which people live. Social work's unique person-in-environment (PIE) approach is an ideal perspective from which to address obesity. This study employs the PIE perspective to examine sprawl, one environmental-level factor. We employed secondary data analysis to examine the effect of sprawl on obesity while controlling for covariates. Region of residence and sprawl significantly predicted obesity, net of covariates. Given that obesity varies among communities, social workers can respond with PIE-oriented solutions.

Scale effects in food environment research: Implications from assessing socioeconomic dimensions of supermarket accessibility in an eight-county region of South Carolina

Choice of neighborhood scale affects associations between environmental attributes and health-related outcomes. This phenomenon, a part of the modifiable areal unit problem, has been described fully in geography but not as it relates to food environment research. Using two administrative-based geographic boundaries (census tracts and block groups), supermarket geographic measures (density, cumulative opportunity and distance to nearest) were created to examine differences by scale and associations between three common U.S. Census-based socioeconomic status (SES) characteristics (median household income, percentage of population living below poverty and percentage of population with at least a high school education) and a summary neighborhood SES z-score in an eight-county region of South Carolina. General linear mixed-models were used. Overall, both supermarket density and cumulative opportunity were higher when using census tract boundaries compared to block groups. In analytic models, higher median household income was significantly associated with lower neighborhood supermarket density and lower cumulative opportunity using either the census tract or block group boundaries, and neighborhood poverty was positively associated with supermarket density and cumulative opportunity. Both median household income and percent high school education were positively associated with distance to nearest supermarket using either boundary definition, whereas neighborhood poverty had an inverse association. Findings from this study support the premise that supermarket measures can differ by choice of geographic scale and can influence associations between measures. Researchers should consider the most appropriate geographic scale carefully when conducting food environment studies.

Greater access to fast-food outlets is associated with poorer bone health in young children

SUMMARY

A healthy diet positively influences childhood bone health, but how the food environment relates to bone development is unknown. Greater neighbourhood access to fast-food outlets was associated with lower bone mass among infants, while greater access to healthy speciality stores was associated with higher bone mass at 4 years.

INTRODUCTION

Identifying factors that contribute to optimal childhood bone development could help pinpoint strategies to improve long-term bone health. A healthy diet positively influences bone health from before birth and during childhood. This study addressed a gap in the literature by examining the relationship between residential neighbourhood food environment and bone mass in infants and children.

METHODS

One thousand one hundred and seven children participating in the Southampton Women's Survey, UK, underwent measurement of bone mineral density (BMD) and bone mineral content (BMC) at birth and 4 and/or 6 years by dual-energy X-ray absorptiometry (DXA). Cross-sectional observational data describing food outlets within the boundary of each participant's neighbourhood were used to derive three measures of the food environment: the counts of fast-food outlets, healthy speciality stores and supermarkets.

RESULTS

Neighbourhood exposure to fast-food outlets was associated with lower BMD in infancy (β = -0.23 (z-score): 95% CI -0.38, -0.08) and lower BMC after adjustment for bone area and confounding variables (β = -0.17 (z-score): 95% CI -0.32, -0.02). Increasing neighbourhood exposure to healthy speciality stores was associated with higher BMD at 4 and 6 years (β = 0.16(z-score): 95% CI 0.00, 0.32 and β = 0.13(z-score): 95% CI -0.01, 0.26 respectively). The relationship with BMC after adjustment for bone area and confounding variables was statistically significant at 4 years, but not at 6 years.

CONCLUSIONS

The neighbourhood food environment that pregnant mothers and young children are exposed may affect bone development during early childhood. If confirmed in future studies, action to reduce access to fast-food outlets could have benefits for childhood development and long-term bone health.

The relationship between unhealthy food sales, socio-economic deprivation and childhood weight status: results of a cross-sectional study in England

BACKGROUND

Recent increases in obesity prevalence have led to research into the neighbourhood food environment. Research suggests that proximity and density of food outlets around the home is associated with childhood obesity prevalence, however, the evidence is inconclusive, and associations between food outlet locations and diet are less clear. The purpose of this study is to assess area level associations between sales of unhealthy foods in supermarkets and weight status of children.

METHODS

This study examined the association between weight status in children (4-5 year olds and 10-11 year olds) measured in the National Child Measurement Programme over three time points (2008/9, 2009/10, 2010/11) and annual sales of unhealthy foods (2012/3), as identified from a large supermarket chain. Geographical analysis was conducted to link store-based food sales for 537 stores with 6517 UK Census Areas. Unadjusted associations were examined with error-bar plots and linear regression was used to examine the relationship between the prevalence of overweight and obesity and sales of unhealthy food, while controlling for covariates known to predict weight status in children.

RESULTS

A statistically significant relationship was identified between the sales of unhealthy foods and the prevalence of overweight and obese children in both age groups (p < 0.01). Of the covariates, area deprivation was positively associated with weight status (p < 0.001). Non-white population (%) was negatively associated (p < 0.001) with overweight and obesity among Reception children, but positively associated with the other weight statuses (p < 0.001). A higher proportion of children in the same age group were associated with statistically significantly lower overweight and obesity prevalence in Reception (p <0.01) but not Year 6 children.

CONCLUSIONS

The study provides novel findings linking supermarket food sales with the weight status of children. Food sales in geographically referenced supermarkets are a valuable source of data for research into the factors that influence the weight of the surrounding population. Future research could identify factors that might modify food shopping in supermarkets and use of purchasing data could be an effective way to measure the impact of healthy eating campaigns on the weight status of children over time.

Built environment assessment: Multidisciplinary perspectives

Context

As obesity has become increasingly widespread, scientists seek better ways to assess and modify built and social environments to positively impact health. The applicable methods and concepts draw on multiple disciplines and require collaboration and cross-learning. This paper describes the results of an expert team׳s analysis of how key disciplinary perspectives contribute to environmental context-based assessment related to obesity, identifies gaps, and suggests opportunities to encourage effective advances in this arena.

Evidence acquisition

A team of experts representing diverse disciplines convened in 2013 to discuss the contributions of their respective disciplines to assessing built environments relevant to obesity prevention. The disciplines include urban planning, public health nutrition, exercise science, physical activity research, public health and epidemiology, behavioral and social sciences, and economics. Each expert identified key concepts and measures from their discipline, and applications to built environment assessment and action. A selective review of published literature and internet-based information was conducted in 2013 and 2014.

Evidence synthesis

The key points that are highlighted in this article were identified in 2014–2015 through discussion, debate and consensus-building among the team of experts. Results focus on the various disciplines׳ perspectives and tools, recommendations, progress and gaps.

Conclusions

There has been significant progress in collaboration across key disciplines that contribute to studies of built environments and obesity, but important gaps remain. Using lessons from interprofessional education and team science, along with appreciation of and attention to other disciplines׳ contributions, can promote more effective cross-disciplinary collaboration in obesity prevention.

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Gaps in collaboration in studies of built environments and obesity remain.

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Lessons from interprofessional education can promote more effective collaboration.

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More attention to other disciplines’ contributions will yield greater health impact.

Geographic disparities in Healthy Eating Index scores (HEI-2005 and 2010) by residential property values: Findings from Seattle Obesity Study (SOS)

BACKGROUND

Higher socioeconomic status (SES) has been linked with higher-quality diets. New GIS methods allow for geographic mapping of diet quality at a very granular level.

OBJECTIVE

To examine the geographic distribution of two measures of diet quality: Healthy Eating Index (HEI 2005 and HEI 2010) in relation to residential property values in Seattle-King County.

METHODS

The Seattle Obesity Study (SOS) collected data from a population-based sample of King County adults in 2008-09. Socio-demographic data were obtained by 20-min telephone survey. Dietary data were obtained from food frequency questionnaires (FFQs). Home addresses were geocoded to the tax parcel and residential property values were obtained from the King County tax assessor. Multivariable regression analyses using 1116 adults tested associations between SES variables and diet quality measured (HEI scores).

RESULTS

Residential property values, education, and incomes were associated with higher HEI scores in bivariate analyses. Property values were not collinear with either education or income. In adjusted multivariable models, education and residential property were better associated with HEI, compared to than income. Mapping of HEI-2005 and HEI-2010 at the census block level illustrated the geographic distribution of diet quality across Seattle-King County.

CONCLUSION

The use of residential property values, an objective measure of SES, allowed for the first visual exploration of diet quality at high spatial resolution: the census block level.

Fast food restaurant locations according to socioeconomic disadvantage, urban-regional locality, and schools within Victoria, Australia

Features of the built environment provide opportunities to engage in both healthy and unhealthy behaviours. Access to a high number of fast food restaurants may encourage greater consumption of fast food products. The distribution of fast food restaurants at a state-level has not previously been reported in Australia. Using the location of 537 fast food restaurants from four major chains (McDonald׳s, KFC, Hungry Jacks, and Red Rooster), this study examined fast food restaurant locations across the state of Victoria relative to area-level disadvantage, urban-regional locality (classified as Major Cities, Inner Regional, or Outer Regional), and around schools. Findings revealed greater locational access to fast food restaurants in more socioeconomically disadvantaged areas (compared to areas with lower levels of disadvantage), nearby to secondary schools (compared to primary schools), and nearby to primary and secondary schools within the most disadvantaged areas of the major city region (compared to primary and secondary schools in areas with lower levels of disadvantage). Adjusted models showed no significant difference in location according to urban-regional locality. Knowledge of the distribution of fast food restaurants in Australia will assist local authorities to target potential policy mechanisms, such as planning regulations, where they are most needed.

Geographic access to food shelves among racial/ethnic minorities and foreign-born residents in the Twin Cities

Place-based disparities in access to affordable food sources (e.g., supermarkets) have been well documented, but geographic access to emergency food sources (e.g., food panties, also known as food shelves) is unknown. This study examined the geography of emergency food in the Twin Cities, MN. U.S. Census and American Community Survey data were used to estimate the average distance to the closest food shelf according to area racial/ethnic composition and foreign-born group composition. In adjusted models, areas with the highest proportion of minority groups had shorter distances to the nearest food shelf (0.13-1.03 log-transformed miles, p <0.05), as did census tracts with more residents born in East Africa and Latin America (0.29-0.31 log-transformed miles, p< 0.001). Areas with more racial/ethnic minorities and foreign-born groups may have access to emergency food, but efforts are needed to evaluate the healthfulness and culturally relevance of these offerings.

Absolute and relative densities of fast-food versus other restaurants in relation to weight status: Does restaurant mix matter?

BACKGROUND

Given the continuing epidemic of obesity, policymakers are increasingly looking for levers within the local retail food environment as a means of promoting healthy weights.

PURPOSE

To examine the independent and joint associations of absolute and relative densities of restaurants near home with weight status in a large, urban, population-based sample of adults.

METHODS

We studied 10,199 adults living in one of four cities in southern Ontario, Canada, who participated in the Canadian Community Health Survey (cycles 2005, 2007/08, 2009/10). Multivariate models assessed the association of weight status (obesity and body mass index) with absolute densities (numbers) of fast-food, full-service and other restaurants, and the relative density (proportion) of fast-food restaurants (FFR) relative to all restaurants within ~10-minute walk of residential areas.

RESULTS

Higher numbers of restaurants of any type were inversely related to excess weight, even in models adjusting for a range of individual covariates and area deprivation. However, these associations were no longer significant after accounting for higher walkability of areas with high volumes of restaurants. In contrast, there was a direct relationship between the proportion of FFR relative to all restaurants and excess weight, particularly in areas with high volumes of FFR (e.g., odds ratio for obesity=2.55 in areas with 5+ FFR, 95% confidence interval: 1.55-4.17, across the interquartile range).

CONCLUSIONS

Policies aiming to promote healthy weights that target the volume of certain retail food outlets in residential settings may be more effective if they also consider the relative share of outlets serving more and less healthful foods.

Economic constraints on taste formation and the true cost of healthy eating

This article shows how an interaction between economic constraints and children's taste preferences shapes low-income families' food decisions. According to studies of eating behavior, children often refuse unfamiliar foods 8 to 15 times before accepting them. Using 80 interviews and 41 grocery-shopping observations with 73 primary caregivers in the Boston area in 2013-2015, I find that many low-income respondents minimize the risk of food waste by purchasing what their children like--often calorie-dense, nutrient-poor foods. High-income study participants, who have greater resources to withstand the cost of uneaten food, are more likely to repeatedly introduce foods that their children initially refuse. Several conditions moderate the relationship between children's taste aversion and respondents' risk aversion, including household-level food preferences, respondents' conceptions of adult authority, and children's experiences outside of the home. Low-income participants' risk aversion may affect children's taste acquisition and eating habits, with implications for socioeconomic disparities in diet quality. This article proposes that the cost of providing children a healthy diet may include the possible cost of foods that children waste as they acquire new tastes.

Global growth of "big box" stores and the potential impact on human health and nutrition

Despite a large body of literature on the food environment, little is known about the role of supercenters in human nutrition and health. The objectives of this review are to examine what is currently known about the association between supercenters, nutrition, and obesity, to identify how supercenters may affect disparities in food access and nutritional quality of food purchases, and to document the rapid rise of supercenters as a source of food purchases in the United States. A case study of Wal-Mart, the largest food retailer in the United States, is presented that demonstrates the major and increasing role of supercenters as a source of packaged food purchases in the United States, particularly among low-income households, as well as the role of supercenters in supplying key nutrients. Taken together, this review and case study highlight the dominant role of supercenters in the US diet and the need to better understand how supercenters can be leveraged to improve the nutritional quality of what consumers buy and eat.

Association between home and school food environments and dietary patterns among 9-11-year-old children in 12 countries

OBJECTIVES

We investigated the roles of home and school environments on dietary patterns among children from 12 countries differing widely in geographic region and levels of human and economic development.

METHODS

The sample included a total of 6685 (54% girls) 9-11-year-old children. Parents/guardians reported the availability of certain foods in the home, and trained researchers performed school audits recording the availability of foods for sale at schools. Foods were then divided into wholesome (nutrient-dense) and empty-calorie (nutrient-poor) foods and scored according to their availability. Children reported if their school provided school lunch and how many times during the last week they had eaten meals prepared away from home and school. Via principal components analysis, data-driven dietary pattern scores were calculated from food frequency questionnaires. Multilevel models were used to study the associations between home and school food environments (wholesome and empty-calorie foods) and dietary patterns (healthy and unhealthy diet pattern scores).

RESULTS

For low unhealthy diet pattern scores, low availability of empty-calorie foods at home was found to be more important than high availability of wholesome foods. More meals eaten outside home and school were associated with the higher unhealthy diet pattern scores. The availability of wholesome foods at home was positively associated with the healthy diet pattern scores. Food availability at school was not associated with the dietary patterns.

CONCLUSIONS

In this sample, the home food environment was more significant than the school food environment in predicting the dietary patterns. The availability of empty-calorie foods was associated with the unhealthy dietary pattern even when the availability of wholesome foods at home was high. Meals prepared away from home contributed to the unhealthy dietary pattern. Therefore, parents should be encouraged to limit the availability of empty-calorie foods and eating outside the home.

Implications of supermarket access, neighbourhood walkability and poverty rates for diabetes risk in an employee population

OBJECTIVE

Diabetes is a growing public health problem, and the environment in which people live and work may affect diabetes risk. The goal of the present study was to examine the association between multiple aspects of environment and diabetes risk in an employee population.

DESIGN

This was a retrospective cross-sectional analysis. Home environment variables were derived using employees' zip code. Descriptive statistics were run on all individual- and zip-code-level variables, stratified by diabetes risk and worksite. A multivariable logistic regression analysis was then conducted to determine the strongest associations with diabetes risk.

SETTING

Data were collected from employee health fairs in a Midwestern health system, 2009-2012.

SUBJECTS

The data set contains 25 227 unique individuals across four years of data. From this group, using an individual's first entry into the database, 15 522 individuals had complete data for analysis.

RESULTS

The prevalence of high diabetes risk in this population was 2·3 %. There was significant variability in individual- and zip-code-level variables across worksites. From the multivariable analysis, living in a zip code with higher percentage of poverty and higher walk score was positively associated with high diabetes risk, while living in a zip code with higher supermarket density was associated with a reduction in high diabetes risk.

CONCLUSIONS

Our study underscores the important relationship between poverty, home neighbourhood environment and diabetes risk, even in a relatively healthy employed population, and suggests a role for the employer in promoting health.

Moving Beyond "Food Deserts": Reorienting United States Policies to Reduce Disparities in Diet Quality

Jason Block and S. V. Subramanian explore avenues for improving the health of Americans through reducing dietary inequalities and look at whether concern over "food deserts" has been taken too far.

Feeding children in a favela in Rio de Janeiro, Brazil: how much is spent and what would be the cost of a healthy diet?

Abstract Objectives: to measure food expenditure for children living in a favela in Rio de Janeiro, and compare this expenditure to the cost of a healthy diet, based on local prices. Methods: panel study, with three collection dates – 2004, 2008 and 2012 – conducted in children (5 to 9 years old) in Manguinhos. Food prices were collected by way of a sample of local food stores in 2013 and deflated using indicators specific to food prices. Twenty-four hour diet recall, qualitative food frequency and the Brazilian food pyramid adequate for the age group were used to estimate the observed expenditure and the cost of a healthy diet. Results: in 2004, 49.2% of the families interviewed lived on less than US$1 per person/day and 9.7% in 2012.In the same period, the percentage of students eating free school meals dropped from 73% to 49%. Money spent on food was concentrated on sugary products (32.4%) and snacks (12.5%). The estimated monthly cost of a healthy diet (US$142) was lower than the observed expenditure (US$176). Conclusions: increased purchasing power has not led to healthier food choices. The common belief that poor people choose food based on prices was rejected by the present study. Other factors certainly play an important role in food purchasing decisions.

Multiple pathways from the neighborhood food environment to increased body mass index through dietary behaviors: A structural equation-based analysis in the CARDIA study

OBJECTIVES

To examine longitudinal pathways from multiple types of neighborhood restaurants and food stores to BMI, through dietary behaviors.

METHODS

We used data from participants (n=5114) in the United States-based Coronary Artery Risk Development in Young Adults study and a structural equation model to estimate longitudinal (1985-86 to 2005-06) pathways simultaneously from neighborhood fast food restaurants, sit-down restaurants, supermarkets, and convenience stores to BMI through dietary behaviors, controlling for socioeconomic status (SES) and physical activity.

RESULTS

Higher numbers of neighborhood fast food restaurants and lower numbers of sit-down restaurants were associated with higher consumption of an obesogenic fast food-type diet. The pathways from food stores to BMI through diet were inconsistent in magnitude and statistical significance.

CONCLUSIONS

Efforts to decrease the numbers of neighborhood fast food restaurants and to increase the numbers of sit-down restaurant options could influence diet behaviors. Availability of neighborhood fast food and sit-down restaurants may play comparatively stronger roles than food stores in shaping dietary behaviors and BMI.

Cross-national comparison of socioeconomic inequalities in obesity in the United States and Canada

INTRODUCTION

Prior cross-national studies of socioeconomic inequalities in obesity have only compared summary indices of inequality but not specific, policy-relevant dimensions of inequality: (a) shape of the socioeconomic gradient in obesity, (b) magnitude of differentials in obesity across socioeconomic levels and, (c) level of obesity at any given socioeconomic level. We use unique data on two highly comparable societies - U.S. and Canada - to contrast each of these inequality dimensions.

METHODS

Data came from the 2002/2003 Joint Canada/U.S. Survey of Health. We calculated adjusted prevalence ratios (APRs) for obesity (compared to normal weight) by income quintile and education group separately for both nations and, between Canadians and Americans in the same income or education group.

RESULTS

In the U.S., every socioeconomic group except the college educated had significant excess prevalence of obesity. By contrast in Canada, only those with less than high school were worse off, suggesting that the shape of the socioeconomic gradient differs in the two countries. U.S. differentials between socioeconomic levels were also larger than in Canada (e.g., PR quintile 1 compared to quintile 5 was 1.82 in the U.S. [95 % CI: 1.52-2.19] but 1.45 in Canada [95 % CI: 1.10-1.91]). At the lower end of the socioeconomic gradient, obesity was more prevalent in the U.S. than in Canada.

CONCLUSIONS

Our results suggest there is variation between U.S. and Canada in different dimensions of socioeconomic inequalities in obesity. Future research should examine a broader set of nations and test whether specific policies or environmental exposures can explain these differences.

Finding Food Deserts

Public health research has increasingly focused on how access to resources affects health behaviors. Mapping environmental factors, such as distance to a supermarket, can identify intervention points toward improving food access in low-income and minority communities. However, the existing literature provides little guidance on choosing the most appropriate measures of spatial access. This study compared the results of different measures of spatial access to large food stores and the locations of high and low access identified by each. The data set included U.S. Census population data and the locations of large food stores in the six-county area around Chicago, Illinois. Six measures of spatial access were calculated at the census block group level and the results compared. The analysis found that there was little agreement in the identified locations of high or low access between measures. This study illustrates the importance of considering the access measure used when conducting research, interpreting results, or comparing studies. Future research should explore the correlation of different measures with health behaviors and health outcomes.

Geographic measures of retail food outlets and perceived availability of healthy foods in neighbourhoods

OBJECTIVE

To examine associations between geographic measures of retail food outlets and perceived availability of healthy foods.

DESIGN

Cross-sectional.

SETTING

A predominantly rural, eight-county region of South Carolina, USA.

SUBJECTS

Data from 705 household shoppers were analysed using ordinary least-squares regression to examine relationships between geographic measures (presence and distance) of food outlets obtained via a geographic information system and perceived availability of healthy foods (fresh fruits and vegetables and low-fat foods).

RESULTS

The presence of a supermarket within an 8·05 km (5-mile) buffer area was significantly associated with perceived availability of healthy foods (β=1·09, P=0·025) when controlling for all other food outlet types. However, no other derived geographic presence measures were significant predictors of perceived availability of healthy foods. Distances to the nearest supermarket (β=-0·16, P=0·003), dollar and variety store (β=-0·15, P=0·005) and fast-food restaurant (β=0·11, P=0·015) were all significantly associated with perceptions of healthy food availability.

CONCLUSIONS

Our results suggest that distance to food outlets is a significant predictor of healthy food perceptions, although presence is sensitive to boundary size. Our study contributes to the understanding and improvement of techniques that characterize individuals' food options in their community.

Reduced-Item Food Audits Based on the Nutrition Environment Measures Surveys

INTRODUCTION

The community food environment may contribute to obesity by influencing food choice. Store and restaurant audits are increasingly common methods for assessing food environments, but are time consuming and costly. A valid, reliable brief measurement tool is needed. The purpose of this study was to develop and validate reduced-item food environment audit tools for stores and restaurants.

METHODS

Nutrition Environment Measures Surveys for stores (NEMS-S) and restaurants (NEMS-R) were completed in 820 stores and 1,795 restaurants in West Virginia, San Diego, and Seattle. Data mining techniques (correlation-based feature selection and linear regression) were used to identify survey items highly correlated to total survey scores and produce reduced-item audit tools that were subsequently validated against full NEMS surveys. Regression coefficients were used as weights that were applied to reduced-item tool items to generate comparable scores to full NEMS surveys. Data were collected and analyzed in 2008-2013.

RESULTS

The reduced-item tools included eight items for grocery, ten for convenience, seven for variety, and five for other stores; and 16 items for sit-down, 14 for fast casual, 19 for fast food, and 13 for specialty restaurants-10% of the full NEMS-S and 25% of the full NEMS-R. There were no significant differences in median scores for varying types of retail food outlets when compared to the full survey scores. Median in-store audit time was reduced 25%-50%.

CONCLUSIONS

Reduced-item audit tools can reduce the burden and complexity of large-scale or repeated assessments of the retail food environment without compromising measurement quality.

Neighborhood Food Environment, Diet, and Obesity Among Los Angeles County Adults, 2011

INTRODUCTION

The objective of this study was to examine whether an association exists between the number and type of food outlets in a neighborhood and dietary intake and body mass index (BMI) among adults in Los Angeles County. We also assessed whether this association depends on the geographic size of the food environment.

METHODS

We analyzed data from the 2011 Los Angeles County Health Survey. We created buffers (from 0.25 to 3.0 miles in radius) centered in respondents' residential addresses and counted the number of food outlets by type in each buffer. Dependent variables were weekly intake of fruits and vegetables, sugar-sweetened beverages, and fast food; BMI; and being overweight (BMI ≥25.0 kg/m(2)) or obese (BMI ≥30.0 kg/m(2)). Explanatory variables were the number of outlets classified as fast-food outlets, convenience stores, small food stores, grocery stores, and supermarkets. Regressions were estimated for all sets of explanatory variables and buffer size combinations (150 total effects).

RESULTS

Only 2 of 150 effects were significant after being adjusted for multiple comparisons. The number of fast-food restaurants in nonwalkable areas (in a 3.0-mile radius) was positively associated with fast-food consumption, and the number of convenience stores in a walkable distance (in a 0.25-mile radius) was negatively associated with obesity.

DISCUSSION

Little evidence was found for associations between proximity of respondents' homes to food outlets and dietary intake or BMI among adults in Los Angeles County. A possible explanation for the null finding is that shopping patterns are weakly related to neighborhoods in Los Angeles County because of motorized transportation.

Correlates of dietary behavior in adults: an umbrella review

CONTEXT

Multiple studies have been conducted on correlates of dietary behavior in adults, but a clear overview is currently lacking.

OBJECTIVE

An umbrella review, or review-of-reviews, was conducted to summarize and synthesize the scientific evidence on correlates and determinants of dietary behavior in adults.

DATA SOURCES

Eligible systematic reviews were identified in four databases: PubMed, PsycINFO, The Cochrane Library, and Web of Science. Only reviews published between January 1990 and May 2014 were included.

STUDY SELECTION

Systematic reviews of observable food and dietary behavior that describe potential behavioral determinants of dietary behavior in adults were included. After independent selection of potentially relevant reviews by two authors, a total of 14 reviews were considered eligible.

DATA EXTRACTION

For data extraction, the importance of determinants, the strength of the evidence, and the methodological quality of the eligible reviews were evaluated. Multiple observers conducted the data extraction independently.

DATA SYNTHESIS

Social-cognitive determinants and environmental determinants (mainly the social-cultural environment) were included most often in the available reviews. Sedentary behavior and habit strength were consistently identified as important correlates of dietary behavior. Other correlates and potential determinants of dietary behavior, such as motivational regulation, shift work, and the political environment, have been studied in relatively few studies, but results are promising.

CONCLUSIONS

The multitude of studies conducted on correlates of dietary behavior provides mixed, but sometimes quite convincing, evidence. However, because of the generally weak research design of the studies covered in the available reviews, the evidence for true determinants is suggestive, at best.

Food advertising to children and its effects on diet: review of recent prevalence and impact data

In the context of a global obesity epidemic that has led to an unprecedented burden of non-communicable disease, the role of food and beverage marketing to children has been scrutinised in numerous studies. This article discusses the broader concept of an obesity-promoting food environment, before reviewing key, recent (last 5 yr) international research findings with regard to both the prevalence and effects of food and beverage advertising on children's intake. Evidence relating to the two main avenues of food marketing exposure, television, and the Internet, is explored and consideration is given to the differences in consumer experience of these types of promotion. Despite methodological differences and the varying population samples studied, the outcomes are broadly consistent - food advertising is prevalent, it promotes largely energy dense, nutrient poor foods, and even short-term exposure results in children increasing their food consumption. Policymakers are implored to drive forward meaningful changes in the food environment to support healthier choices and reduce the incidence of obesity and related diseases. This article aims at providing an overview of recent developments in this field. After limiting the search to the last five full years 2009-2014, we searched the following databases: Web of Knowledge and PubMed (keyword search terms used: television, Internet, new media, food advertising, food marketing, children, food intake, energy intake, consumption, and combinations of these terms). In addition we used the references from the articles obtained by this method to check for additional relevant material.

Associations between Food Outlets around Schools and BMI among Primary Students in England: A Cross-Classified Multi-Level Analysis

INTRODUCTION

Researchers and policy-makers are interested in the influence that food retailing around schools may have on child obesity risk. Most previous research comes from North America, uses data aggregated at the school-level and focuses on associations between fast food outlets and school obesity rates. This study examines associations between food retailing and BMI among a large sample of primary school students in Berkshire, England. By controlling for individual, school and home characteristics and stratifying results across the primary school years, we aimed to identify if the food environment around schools had an effect on BMI, independent of socio-economic variables.

METHODS

We measured the densities of fast food outlets and food stores found within schoolchildren's home and school environments using Geographic Information Systems (GIS) and data from local councils. We linked these data to measures from the 2010/11 National Child Measurement Programme and used a cross-classified multi-level approach to examine associations between food retailing and BMI z-scores. Analyses were stratified among Reception (aged 4-5) and Year 6 (aged 10-11) students to measure associations across the primary school years.

RESULTS

Our multilevel model had three levels to account for individual (n = 16,956), home neighbourhood (n = 664) and school (n = 268) factors. After controlling for confounders, there were no significant associations between retailing near schools and student BMI, but significant positive associations between fast food outlets in home neighbourhood and BMI z-scores. Year 6 students living in areas with the highest density of fast food outlets had an average BMI z-score that was 0.12 (95% CI: 0.04, 0.20) higher than those living in areas with none.

DISCUSSION

We found little evidence to suggest that food retailing around schools influences student BMI. There is some evidence to suggest that fast food outlet densities in a child's home neighbourhood may have an effect on BMI, particularly among girls, but more research is needed to inform effective policies targeting the effects of the retail environment on child obesity.

Development of the Perceived Nutrition Environment Measures Survey

INTRODUCTION

Objective, observational measures of nutrition environments are now well established and widely used. Individuals' perceptions of their nutrition environments may be equally or more important, but are less well conceptualized, and comprehensive measures are not available. This paper describes the development of the Perceived Nutrition Environment Measures Survey (NEMS-P), its test-retest reliability, and its ability to discern differences between lower- and higher-SES neighborhoods.

METHODS

This research involved five steps: (1) development of a conceptual model and inventory of items; (2) expert review; (3) pilot testing and cognitive interviews; (4) revising the survey; and (5) administering the revised survey to participants in neighborhoods of high and low SES on two occasions to evaluate neighborhood differences and test-retest reliability. Data were collected in 2010 and 2011 and analyzed in 2011 and 2012.

RESULTS

The final survey has 118 items. Fifty-three core items represent three types of perceived nutrition environments: community nutrition environment, consumer nutrition environment, and home food environment. Test-retest reliability for core constructs of perceived nutrition environments was moderate to good (0.52-0.83) for most measured constructs. Residents of higher-SES neighborhoods reported higher availability scores in stores, stronger agreement that healthy options were available in nearby restaurants, and higher scores for accessibility of healthy foods in their homes.

CONCLUSIONS

The NEMS-P has moderate to good test-retest reliability and can discriminate perceptions of nutrition environments between residents of higher- and lower-SES neighborhoods. This survey is available and ready to be used.

Marriage and parenthood in relation to obesogenic neighborhood trajectories: The CARDIA study

Marriage and parenthood are associated with weight gain and residential mobility. Little is known about how obesity-relevant environmental contexts differ according to family structure. We estimated trajectories of neighborhood poverty, population density, and density of fast food restaurants, supermarkets, and commercial and public physical activity facilities for adults from a biracial cohort (CARDIA, n=4,174, aged 25-50) over 13 years (1992-93 through 2005-06) using latent growth curve analysis. We estimated associations of marriage, parenthood, and race with the observed neighborhood trajectories. Married participants tended to live in neighborhoods with lower poverty, population density, and availability of all types of food and physical activity amenities. Parenthood was similarly but less consistently related to neighborhood characteristics. Marriage and parenthood were more strongly related to neighborhood trajectories in whites (versus blacks), who, in prior studies, exhibit weaker associations between neighborhood characteristics and health. Greater understanding of how interactive family and neighborhood environments contribute to healthy living is needed.

The Outdoor MEDIA DOT: The development and inter-rater reliability of a tool designed to measure food and beverage outlets and outdoor advertising

Few studies of the food environment have collected primary data, and even fewer have reported reliability of the tool used. This study focused on the development of an innovative electronic data collection tool used to document outdoor food and beverage (FB) advertising and establishments near 43 middle and high schools in the Outdoor MEDIA Study. Tool development used GIS based mapping, an electronic data collection form on handheld devices, and an easily adaptable interface to efficiently collect primary data within the food environment. For the reliability study, two teams of data collectors documented all FB advertising and establishments within one half-mile of six middle schools. Inter-rater reliability was calculated overall and by advertisement or establishment category using percent agreement. A total of 824 advertisements (n=233), establishment advertisements (n=499), and establishments (n=92) were documented (range=8-229 per school). Overall inter-rater reliability of the developed tool ranged from 69-89% for advertisements and establishments. Results suggest that the developed tool is highly reliable and effective for documenting the outdoor FB environment.

Development of the good food planning tool: A food system approach to food security in indigenous Australian remote communities

Few frameworks exist to assist food system planning, especially for Indigenous Australian remote communities. We developed a Good Food Planning Tool to support stakeholders to collectively plan and take action for local food system improvement. Development occurred over a four-year period through an evolving four phase participatory process that included literature review, several meetings with representatives of various organisations and communities and application of the Tool with multi-sector groups in each of four Indigenous Australian remote communities. A diverse range of 148 stakeholders, 78 of whom were Indigenous, had input to its development. Five food system domains: (i) Leadership and partnerships; (ii) Traditional food and local food production; (iii) Food businesses; (iv) Buildings, public places and transport; (v) Community and services and 28 activity areas form the framework of the Tool. The Good Food Planning Tool provides a useful framework to facilitate collective appraisal of the food system and to identify opportunities for food system improvement in Indigenous Australian remote communities, with potential for adaptation for wider application.

The role of the local retail food environment in fruit, vegetable and sugar-sweetened beverage consumption in Brazil

Objective

To examine the relationship between the local retail food environment and consumption of fruits and vegetables (FV) and sugar-sweetened beverages (SSB) in São Paulo, Brazil, as well as the moderation effects of income in the studied relationships.

Design

Cross-sectional study design that drew upon neighbourhood- and individual-level data. For each participant, community (density and proximity) and community food environment (availability, variety, quality and price) measures of FV and SSB were assessed in retail food stores and specialized fresh produce markets within 1·6 km of their homes. Poisson generalized estimating equations (GEE) were used to model the associations of food consumption with food environment measures, adjusted by individual-level characteristics.

Setting

São Paulo, Brazil.

Subjects

Adults (n 1842) residing in the same census tracts (n 52) in São Paulo, Brazil as those where the neighbourhood-level measures were taken.

Results

FV availability in neighbourhoods was associated with regular FV consumption (≥5 times/week; prevalence ratio=1·41; 95 % CI 1·19, 1·67). Regular FV consumption prevalence was significantly lower among lower-income individuals living in neighbourhoods with fewer supermarkets and fresh produce markets (P-interaction <0·05). A greater variety of SSB was associated with a 15 % increase in regular SSB consumption (≥5 times/week) prevalence, after adjustment for confounding variables.

Conclusions

Our findings suggest that the local retail food environment is associated with FV and SSB consumption in a Brazilian urban sample.